Virtual Mentor. May 2009, Volume 11, Number 5: 373-377.
Medical Business Ethics Education: Guarding the Patient-Centered Focus of Medicine
The Bander Center for Medical Business Ethics’ goals and programs.
James M. DuBois, PhD, DSc
As professionals, we sometimes act like Jean Piaget’s young subjects who focused on only one feature of a container—e.g., its height—when estimating the quantity of liquid it could hold . Such “centrated” children would, for example, reason that, of several 12-ounce containers of varying heights and widths, the tallest would hold the most. One of the principal tasks of cognitive development in many domains—including the moral domain—is decentration, which occurs as we move beyond the stage of focusing on one salient feature of a task to the exclusion of others . In approaching an ethical problem in clinical care, for example, we may need to consider many different aspects of a situation—competing stakeholders’ interests, ethical or legal norms that need to be balanced, intentions, social processes for resolving disputes, and the consequences of actions. Ignoring any one piece of the puzzle can lead to disastrous results.
Learning Objective Learn about the goals and programs of the Bander Center for Medical Business Ethics.
Maintaining a Professional Focus on Patients
For physicians, maintaining a broad view in moral decision making can be challenging. The patient-physician relationship is fiduciary, meaning that patients must be able to trust that the physician will prioritize their best interests over his or her own. Thus, it is not contradictory that the American Medical Association’s Principles of Medical Ethics states both:
Other articles in this issue of Virtual Mentor explore how weighing one’s own needs and preferences against those of patients in society may lead to very different professional choices, including the choice of a medical specialty.
Not one of these examples involves bad choice. To the contrary, new knowledge, financial rewards, and providing a dying patient with a transplanted organ are all good intentions. Shifts in focus need not involve bad will; in fact, some evidence suggests that “self-serving biases” are natural and operate subconsciously [8, 9].
In a complex environment, oversight committees, laws, and professional guidelines help physicians hold patients’ interests about their own. For example, institutional review boards (IRBs) play an important role in ensuring that human subjects are properly protected in medical research ; anti-kickback laws can help reduce the exploitation of financial conflicts of interest ; and practice guidelines for the evaluation of living organ donors encourage greater attention to the prospective donor’s well-being .
Nevertheless, such mechanisms are insufficient to ensure that medicine is patient-centered. First, they are frequently reactive—they arise only in response to problems that have been identified and received broad attention. Second, many issues—such as the selection of career specialization—are best resolved according to one’s own convictions and conscience. Third, such mechanisms risk shifting attention away from patients toward compliance for compliance’s sake . In the end, professional education and mentoring—not regulations and codes—remain essential to engaging matters of focus and integrity.
Bander Center for Medical Business Ethics
With a generous endowment from Steven Bander, MD, Saint Louis University established the Bander Center for Medical Business Ethics in 2008. The mission of the Bander Center is:
The center’s educational and training programs are designed to foster critical reflection and discussion rather than promoting one ideological perspective. Speakers and programs may engage controversial positions, but do so critically and with responses from scholars when feasible. The center seeks to ensure that recommendations regarding practices and policies are grounded in the best available evidence about physician behavior—its influences and impact on patient care. All activities explore how the manifold business dimensions of medical care and research can be managed to preserve a proper focus on the well-being of patients.
One of the center’s most intensive training endeavors involves developing a body of experts in medical business ethics who will serve the university and eventually a broader community of physicians. In the process, a research assistantship (RA) was established to support an MD/PhD student during the doctoral phase of the program in health care ethics. The RA assists in the development of continuing medical education (CME) opportunities, coordinates events, and provides research support for Bander Center faculty and fellows. The RA is encouraged to pursue his or her own research project in the area of medical business ethics. This experience fosters the acquisition of knowledge and academic skills in medical business ethics in an individual who is likely to build a career in academic medicine.
The Bander Center also has a 1-year fellowship program that supports two junior faculty members in the school of medicine each year. The center protects 10 percent of their time for weekly meetings with a mentor, while they research a medical-business-ethics topic of their choice. By the end of the year, they are expected to publish a peer-reviewed article on their topic and produce PowerPoint slides for use in training sessions with medical students or residents. While the Bander Center faculty is interdisciplinary, we believe strongly that physicians should be mentored by physicians. Accordingly, physicians affiliated with the Bander Center direct the fellowship program, mentor residents, and teach medical students.
In addition to these two intensive training and investigation programs, the center offers:
Finally, the Bander Center collaborates with a newly established program at Washington University in St. Louis, the Bander Business Ethics in Medical Research Funding Program, which offers 1-year grants of up to $25,000 to members of the Institute for Clinical and Translational Science to support original research.
Each educational endeavor requires significant dedication of time, resources, and backing from those in charge of medical education, as well as from adult learners themselves.
Especially during challenging economic times, it can be difficult to find adequate resources. Relating medical-business-ethics training to the professionalism requirements of the Accreditation Council of Graduate Medical Education (ACGME) can help garner support within academic medical centers. In establishing the center, we worked closely with our associate deans for undergraduate medical education, graduate medical education, and continuing education, which was essential to the mission of reaching out to physicians from their first weeks in medical school through their years of practice as established specialists. Within the first year, we conducted an online survey of medical school faculty and residents inquiring into the medical-business-ethics topics they thought most important to address, the educational formats they preferred (e.g., online, lectures, journal clubs), and their availability at different times during the week and have tried to tailor the center’s programs to the results of that survey.
Throughout all of our efforts as a center, we constantly engage the question “How might our present topic—e.g., financial conflicts of interest, health care reform, free drug samples, or pay-for-performance—affect patient care?” In the increasingly complex business environment in which medicine operates, this question is more relevant than ever before.
James M. DuBois, PhD, DSc, is the Hubert Mader Professor and chair of the Department of Health Care Ethics at Saint Louis University and adjunct professor of medicine in the Institute for Clinical and Translational Sciences at Washington University in St. Louis. He directs the Bander Center for Medical Business Ethics and is principal investigator on a multiyear study of the environmental predictors of “ethical disasters” in medical practice and research. His book, Ethics in Mental Health Research, addresses conflicts of interest in research, among other topics.
The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
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